Geriatric Grand Rounds

Transcription

1 Geriatric Grand Rounds Primary Prevention in Dementia Tuesday, June 29, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital Geriatric Grand Round June 29, 2010 Lai Man Ma In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event have been asked to disclose to the audience any involvement with industry or other organizations that may potentially influence the presentation of the educational material. Disclosure will be done both verbally and using a slide or handout. DISCLOSURE NONE Objectives Review the landscape of dementia and its impact on Canadian Society Review risk factors and protective factors of dementia Discuss prevention strategies in clinical practice 1

2 Rising Tide: The Impact of Dementia on Canadian Society Published in 2010 by Alzheimer s Society of Canada Gain understanding of demographic and epidemiological profile of dementia in Canada To develop a future picture of health and economic burden of dementia Introduce discussion of how to reduce its impact Dementia Incidence (new case /year) Prevalence Million % of pop. 1.5% 2.8% Prevalence Alzheimer s disease and Vascular Dementia accounts for vast majority of dementia (83%) Female to male ratio for all dementia 1.36 Female to male ratio for AD 2.29 Female to male ratio for VasD 0.85 Impact of Dementia Long term care unable to meet needs Shift to home/community care 65+ with dementia in own home increase from 55% to 62% Represents extra individuals with dementia living in their own homes Increase burden to community services and caregivers 2

3 Caregiver Burden Informal care hours (millions hours) MORE THAN TRIPLE Economic Burden Direct health care cost Opportunity cost of informal caregiver Indirect cost TOTAL ECONOMIC COST 2008 $15 billion 2018 $37 billion 2028 $75 billion 2038 $153 billion DOUBLES EVERY DECADE Why Wait Delaying onset of dementia by 2 years will substantially decrease incidence and prevalence of dementia Reduce strain on health care and resources Reduce caregiver burden and lessen economic impact Risk Factors Non Modifiable Age Genetics APOE4 allele Family history of Alzheimer s Disease Possible risk factors Lack of formal education Low socio-economic status Excess ETOH 3

4 Modifiable Risk Factors Head injury Vascular risk factors Type II Diabetes Hypertension CVA/TIA Dyslipidemia Obesity smoking VASCULAR RISK FACTORS Observational studies Diabetes increases risk of dementia and MCI Hypertension in midlife increase risk of dementia High cholesterol and LDL increase risk of MCI and dementia Midlife obesity increase risk of dementia Metabolic syndrome increase risk of cognitive decline VASCULAR RISK FACTORS Difficult to establish actual mechanism of each of the vascular risk factors Most people have multiple risk factors Likely additive effect and complex interaction between the risk factors Oxidative stress, insulin resistance, adiposity, endothelial dysfunction, inflammation and subcortical vascular diseases PROTECTIVE FACTORS Diet Physical Activity Leisure/Cognitive Activity Social Engagement 4

5 DIET Many of the vascular risk factors for dementia modify by diet Theory diet may reduce risk of dementia Several observational studies support theory Mediterranean Diet Mediterranean Diet Feast et al (Jan 2010) updated knowledge of Mediterranean Diet and dementia based on two prospective cohorts US study France Study Looking at diet, not individual foods Mediterranean Diet Scale Mediterranean Diet is collection of eating pattern Score 0-9 based on adherence to the diet Vegetable Fruits Legumes/nuts Whole grain cereal Mono and polyunsaturated fats olive oil Low to moderate ETOH Fish low-moderate intake Meat:low red meat, low-moderate poultry, <4 eggs/wk Dairy cheese, yogurt Adherence to diet Higher adherence to diet (6-9) had 40% lower risk to develop AD compare to low adherence group (0-3) Also look into MCI and diet Higher adherence 45% lower risk Moderate adherence 48% lower risk 5

6 3 City Study (France) 8085 non-demented subjects older than 65 years enrolled between Followed for 4 years 281 developed dementia of which 183 had AD Daily fruit/vegetable consumption decreased risk by 28% for all dementia Weekly fish consumption decreased risk by 40% all dementia and 35% AD Barberger-Gateau et. Al (2007) Physical Activity Well documented benefit of physical activity Primary and secondary prevention of coronary artery disease Improving lipid profile Reducing body fat mass Prevention of diabetes Prevention of strokes Prevention/control of hypertension Reduce risk of falls Physical Activity Observational studies show physically active people have less cognitive decline and lower risk than sedentary subjects Rovio et al. The Lancet Neurology 2005 Italian study (Ravaglia et al Neurology 2008) US Study (Larson et al, Ann Int Med 2006) Rovio et al. (2005) Survivor subjects from the Cardiovascular risk factor, Aging and Incidence of Dementia study from 1972, 1977, 1982, 1987 were re-examined in 1999 At baseline, subjects (n=2000) completed survey that included health behavior, health status, medical history (age range 39-64) BP, height, weight, BMI measured Serum cholesterol determined Physical limitations were recorded 6

7 Rovio et al One particular question How often do you participate in leisure-time physical activity that last minutes and causes breathlessness and sweating Categorized as Active activity at least twice a week Sedentary activity less than twice a week Rovio et al Subjects (n=1449) were re-examined 1998 using identical survey as in baseline Age range (65-79) Those MMSE less than 24 had more detailed exam 61 diagnosed with dementia (48 had AD) Dementia diagnoses of non-participant added which increase dementia cases to 117 Rovio et al results Active group had approximately 60% lower risk of AD than Sedentary group Similar effect between men and women Other studies showed similar results Why Physical Activity Helps? Exercise stimulate production of growth factors (Brain Derived Neurotropic factors BDNP) Promote connectivity between neurons and preserve their health Exercise maintain good blood supply Increase oxygen to brain Low oxygen promote beta-amyloid AD 7

8 Social Engagement Socially isolated elderly with few interaction with relatives and friends at risk for dementia Rich and large social network provide intellectual stimulation and could influence cognitive function Friends, families, clubs, church, centres Leisure & Mental Activity Different from cognitive training Knitting Gardening Dancing Board games Reading Playing musical instruments Social & cultural activities Leisure activity Scarmeas et al. Neurology (2001) 1772 subjects 65+ without dementia Assessed at baseline and followed yearly for 7 years 13 activities One point for each activity Low activity: less than 6 High activity: greater than or equal to 6 13 activities Knitting or music or other hobby Walking for pleasure or excursion Visiting friends or relative Physical conditioning Going to movies/restaurants or sports events Reading magazine, newspapers or books Watching television/listening to radio Doing unpaid community volunteer work Playing cards/games or bingo Going to a club or centre Going to classes Going to church/synagogue/temple 8

9 Scarmeas et al. results Those with high activity score had 38% less risk of dementia than those with low activity score Activities most strongly associated with reduced risk Reading Visiting friends or relatives Going to movies/restaurants Walking for pleasure or going for an excursion Bronx Aging Study Part of Bronx Aging Study Followed subjects without dementia at baseline at intervals for 21 years Detailed clinical and neuropsychological evaluations Examine influence of cognitive and leisure activity and risk of developing dementia Verghese et al NEJM 2003 Bronx Aging Study English speaking between Mostly middle class, white(91%) and female (64%) Enrolled 488 between Followed every months ( ) Questioned on BADL and IADL, neuropsychological test and leisure activity Verghese et al NEJM 2003 Bronx Aging Study Interviewed on 6 cognitive activity Reading, writing, crossword puzzles, board games/cards, organized group discussion, musical instruments 11 physical activities Tennis/golf, swimming, biking, group exercise, team games, walking, climbing 2 or more flights of stairs, housework, babysitting Daily, several days/week, weekly. Monthly, occasionally, never Verghese et al NEJM

10 Bronx Aging Study Median follow-up was 5.1 years 124 developed dementia (64 with AD) Those with highest tertile cognitive activity scale had 63% lower risk in dementia than those in the lowest tertile scale No benefit of physical activity Verghese et al NEJM 2003 Adult life cognitive activity Epidemiological studies Higher education and high work complexity decreases risk of dementia and AD Reserve hypothesis More development of neural pathways More cognitive reserve even with neuron damages present Cognitive Training ACTIVE TRIAL Ball et al (2002) and Willis et al (2006) 2832 healthy physically and cognitively Age (mean 74) Randomized into 4 groups Memory training Reasoning training Process speed training Control group Cognitive Training 3 intervention groups given ten minutes group sessions over 5-6 weeks Contents abstract and related to daily life 11 months later 60% subjects in each group given booster sessions in same domain Group were tested at 2 years and 5 years 10

11 Cognitive Training At the end of training session, each intervention group improved in respective target cognitive ability Memory group 26% Reasoning group 74% Speed of processing 86% Those with booster training showed better results Cognitive Training At 2 year follow-up cognitive improvement remain for the intervention groups but NO DIFFERENCE IN IADL compare to control group At 5 year follow-up still gains in targeted cognitive ability Only reasoning group show significance in less difficulty with IADL Cognitive Training Conclusion was training with or without booster training showed gains in specific domains even after 5 years Cognitive improvements not translate to improvement in everyday life Memory training least beneficial Similar finding in 2009 review of 7 randomized studies Prevention strategies Implementing interventions aim at risk factors and protective factors during midlife not late life Risk assessment Quantify risk 11

12 Risk Assessment Cardiovascular Risk Factor, Aging and Dementia (CAIDE) from Scandinavia. Kivipelto et al. (2006) Risk score based on Age Education Systolic BP BMI Total cholesterol Physical activity CAIDE STUDY scoring model Age Score BMI Score <47 0 < >30 2 >53 4 Education, yr Total Cholesterol < >6.5 2 <6 3 Systolic BP mmhg PhysicalActivity <140 0 Active 0 >140 2 Inactive 1 Adapated from Patterson et al, CMAJ 2008 CAIDE STUDY scoring model Score Risk % for AD Pros Similar to Framingham score for risk of MI Easy to use and for patients to understand Adapated from Patterson et al, CMAJ

13 Cons Does not address other factors that may contribute to developing dementia Family history, diet, leisure/social activity May contribute to false sense of security May contribute to complacency and decrease motivation to improve one s health or to change one s lifestyle Prevention Strategies Implementing interventions aim at risk factors and protective factors during midlife not late life Target vascular risk factors Mediterranean diet Active lifestyle Socially engaged lifestyle Increase physical activity Vascular Risk Factors VASCULAR RISK FACTORS STRONGLY ASSOCIATED WITH RISK OF DEMENTIA Minimize risks in mid-life TREAT HYPERTENSION Statin therapy Diabetic control/prevention Weight loss Smoking cessation Preventing cerebrovascular diseases Identify patients at risk and screen for dementia/mci Hypertension & Dementia Most robust evidence Only grade A recommendation from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia in 2006 (Patterson et al CMAJ 2008) Pooled data from 4 trial HTVET-COG, SHEP, SYST-EUR, PROGRESS Antihypertensive treatment reduce risk of dementia by 13% 13

14 Rising Tide Report Increase Physical Activity increasing level of activity by 50% for Canadians (65+) without dementia who are already moderately active Short-term (10 years) (2018) Reduce incidence by 4.3% (5 970) Reduce prevalence by 5.1% (32 450) 13,570 fewer patients with dementia in LTC (-7.4%) Reduction of total economic burden by $5.6 billion Rising Tide Report Increase Physical Activity 30 Year impact 2038 Reduce incidence by 4.2% (10,750) Reduce prevalence by 8.6% (96,410) 36,210 fewer patients with dementia in LTC (-8.2%) Reduction of total economic burden by $51.8 billion 50% increase physical activity Realistic or not? Prevention strategies Clinical Setting treat cardiovascular co-morbidities counsel on diet and weight management Dietician involvement encourage physical activity encourage retirees to be socially engaged educate patients and screen those at risk 14

15 Prevention Strategies Regional and Public Health Educate health care providers about primary prevention for dementia Public awareness for risk and prevention of dementia More services/programs to promote healthy lifestyle gear towards seniors Up coming studies Dose - response to exercise training Cognitive sub-study of the Finnish Diabetes Prevention Study The Finnish Geriatric Intervention Study to prevent Cognitive Impairment and Disability (FINGER) FINGER study 2 year multi-domain intervention Nutritional guidance Physical activity Cognitive training and social activity Intensive monitoring and management of metabolic and vascular risk factor First randomized intervention trial to see if multidomain intervention will delay onset of MCI and dementia in those with increased risk factors QUESTIONS 15